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International audience; OBJECTIVE:To determine whether extrauterine growth is associated with neurologic outcomes and if this association varies by prenatal growth profile.STUDY DESIGN:For 1493 preterms from the EPIPAGE (Étude Épidémiologique sur les Petits Âges Gestationnels [Epidemiological Study on Small Gestational Ages]) cohort, appropriate for gestational-age (AGA) was defined by birth weight >-2 SD and small for gestational-age (SGA) by birth weight ≤-2 SD. Extra-uterine growth was defined by weight gain or loss between birth and 6 months by z-score change. Growth following-the-curve (FTC) was defined as weight change -1 to +1 SD, catch-down-growth (CD) as weight loss ≥1 SD, and catch-up-growth (CU) as weight gain ≥1 SD. At 5 years, a complete medical examination (n = 1305) and cognitive evaluation with the Kauffman Assessment Battery for Children (n = 1130) were performed. Behavioral difficulties at 5 years and school performance at 8 years were assessed (n = 1095).RESULTS:Overall, 42.5% of preterms were AGA-FTC, 20.2% AGA-CD, 17.1% AGA-CU, 5.6% SGA-FTC, and 14.5% SGA-CU. Outcomes did not differ between CU and FTC preterm AGA infants. Risk of cerebral palsy was greater for AGA-CD compared with AGA-FTC (aOR 2.26 [95% CI 1.37-3.72]). As compared with children with SGA-CU, SGA-FTC children showed no significant increased risk of cognitive deficiency (aOR 1.41[0.94-2.12]) or school difficulties (aOR 1.60 [0.84-3.03]). Compared with AGA-FTC, SGA showed increased risk of cognitive deficiency (SGA-FTC aOR 2.19 [1.25-3.84]) and inattention-hyperactivity (SGA-CU aOR 1.65 [1.05-2.60]).CONCLUSION:Deficient postnatal growth was associated with poor neurologic outcome for AGA and SGA preterm infants. CU growth does not add additional benefits. Regardless of type of postnatal growth, SGA infants showed behavioral problems and cognitive deficiency.

Aim: The first results from the French National Prader-Willi pediatric database in a cohort of 142 children aged 0.2–18.8 years are reported. This database gathers information about the endocrine dysfunctions traditionally described in Prader-Willi patients. Methods: Questionnaires were filled in by the patients’ practitioners. The coordination team of the reference center performed the statistical analysis. Results: Median BMI Z-score was +1.3 for a median age of 7.1 years, and 40% of the population were overweight or obese (International Obesity Task Force 2000 criteria). Growth hormone deficiency was present in 80% of patients and 86.7% were treated, with a height gain of +1 SD and a BMI reduction of –0.8 Z-score achieved in the first year of treatment. Hypogonadism was present in 49% of patients, and hypothyroidism in 24.4%. Glucose intolerance was found in 4% of patients, but no diabetes mellitus was detected in the 74 patients explored. Conclusion: Our report gives an overview of endocrine dysfunctions recorded in a large registry database of French children and adolescents with Prader-Willi syndrome. The database, which now encompasses six southern regions of France, will be further extended to the whole country and to adult patients.

The aim of the present case study was to present and discuss the analysis of triadic nonverbal communication between mother, infant, and therapist in two early consultations as an indicator of the therapeutic alliance. The analysis explored nonverbal triadic interactions (body positions and facial orientations of the mother, infant, and therapist, and expressive behaviors of the infant) and triadic affective sharing (via a microanalytic interview of the therapist). The quality of the therapeutic alliance and clinical outcome for each case are described. The description of the two cases illustrates the importance of the progressive development of nonverbal "engagement" by the three people (triadic alliance) and of moments with triadic emotional sharing. The contribution of the therapist appears to be crucial, in particular via his or her body and affective engagement with the infant. The triadic alliance appears to be both an indicator of the therapeutic alliance and an element that can foster it.

To examine parent-professional agreement in proxy-reports of child quality of life (QoL) and the factors associated with low child QoL in children with cerebral palsy (CP) and associated intellectual impairment. Professional (teacher, therapist, or residential carer) and parent reports of QoL for 204 children (127 males, 77 females, mean age 10 y 4 mo [SD 1y 6mo]; range 8-12 y) with CP and IQor=70 were obtained in 2004 to 2005 in nine European regions, using the KIDSCREEN questionnaire. Parent-professional agreement was studied using correlation and mean differences; multilevel logistic regression was used to determine factors influencing QoL reports and agreement. The mean parent-reported scores of child QoL were significantly higher than the professional reports in the Psychological well-being domain and significantly lower for Social support. The average frequency of disagreement (parent-professional difference0.5SD of scores) over all domains was 62%. High levels of stress in parenting negatively influenced parent reports of child QoL compared with professional reports, while child pain was associated with professionals rating lower than parents. Proxies do not always agree when reporting the QoL of children with severe disabilities. Parental well-being and child pain should be taken into account in the interpretation of QoL reports in such children.

Resume Objectif Malgre d’indiscutables progres, la protection des adolescents lors des premiers rapports sexuels n’est pas parfaite. Les principaux risques en sont bien identifies (infections sexuellement transmissibles [IST], grossesses non desirees, voire consequences psychiques) et semblent majores lors de relations sexuelles precoces. Cette etude epidemiologique analyse chez les filles les facteurs associes aux relations heterosexuelles precoces (15 ans ou avant), considerees comme facteurs de risque pour les grossesses et les IST. Population et methodes Nos donnees proviennent de l’enquete internationale Health Behaviour in School-aged Children (HBSC)/OMS de 2002. Cette enquete anonyme par autoquestionnaire complete en classe porte sur la sante, les comportements de sante et leurs contextes chez les eleves de 11, 13 et 15 ans. Ces derniers avaient a repondre a des questions sur leur sexualite. En France, 1264 filles de 15 ans plus ou moins six mois ont repondu. Resultats Deux cent vingt-quatre filles (17,7 %) ont declare avoir deja eu des rapports sexuels dont 88,4 % ont utilise le preservatif et/ou la pilule au dernier rapport. Selon les analyses multivariees realisees sur 1159 filles, sept variables sont significativement et independamment associees a une frequence superieure d’experience sexuelle precoce : famille recomposee ou monoparentale, ivresses repetees, consommation quotidienne de tabac, experimentation du cannabis, sorties frequentes le soir entre amis, appreciation plutot negative de sa vie et menarche a 12 ans ou moins. Discussion et conclusion L’identification des differents facteurs associes a la precocite des premieres relations sexuelles devrait permettre aux professionnels une prise en charge plus ciblee et plus precoce de ces adolescentes particulierement a risque.

Objective To assess the cost-effectiveness of an internet-based, nurse-led vascular risk factor management programme in addition to usual care compared with usual care alone in patients with a clinical manifestation of a vascular disease. Design Cost-effectiveness analysis alongside a randomised controlled trial (the Internet-based vascular Risk factor Intervention and Self-management (IRIS) study). Setting Multicentre trial in a secondary and tertiary healthcare setting. Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with ≥2 treatable vascular risk factors not at goal. Intervention The intervention consisted of a personalised website with an overview and actual status of patients’ vascular risk factors, and mail communication with a nurse practitioner via the website for 12 months. The intervention combined self-management support, monitoring of disease control and pharmacotherapy. Main outcome measures Societal costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness. Results Patients experienced equal health benefits, that is, 0.86 vs 0.85 QALY (intervention vs usual care) at 1 year. Adjusting for baseline differences, the incremental QALY difference was −0.014 (95% CI −0.034 to 0.007). The intervention was associated with lower total costs (€4859 vs €5078, difference €219, 95% CI −€2301 to €1825). The probability that the intervention is cost-effective at a threshold value of €20 000/QALY, is 65%. At mean annual cost of €220 per patient, the intervention is relatively cheap. Conclusions An internet-based, nurse-led intervention in addition to usual care to improve vascular risk factors in patients with a clinical manifestation of a vascular disease does not result in a QALY gain at 1 year, but has a small effect on vascular risk factors and is associated with lower costs. Trial registration number NCT00785031.

Position du probleme L’impact des conditions de vie sur la sante est encore mal connu, mais les inegalites de sante observees chez l’adulte semblent en partie determinees par les comportements et la sante a un âge precoce, et plus particulierement pendant l’adolescence. Notre objectif etait donc d’etudier, en fonction du statut socio-economique familial, la sante et les comportements de sante des adolescents. Methodes Nous avons analyse les donnees francaises de l’enquete internationale « Health Behaviour in School-aged Children » realisee a partir d’un echantillon representatif d’adolescents âges de 13 et 15 ans en 1998. Les adolescents ont repondu a un questionnaire auto-administre explorant la sante, les comportements de sante et le statut socio-economique familial. Resultats Les adolescents issus de familles d’ouvriers etaient plus nombreux a declarer etre en « assez bonne sante » ou « pas tres bonne sante » (OR = 1,40, IC 95 % = 1,12-1,74) et en surpoids ou obese (OR = 1,85, IC 95 % = 1,25-2,24) que ceux issus de familles de cadres. Ils etaient egalement plus nombreux a adopter des comportements nefastes a la sante (hygiene alimentaire, pratique sportive) par rapport a ceux issus de familles de cadres. Conclusion Cette etude a mis en evidence, chez les adolescents, des differences en termes de sante, de comportements de sante, d’alimentation et d’activite physique, liees au statut socio-economique de la famille.

Summary Background A cross-sectional, descriptive, questionnaire-based survey was conducted in Toulouse schools to determine the prevalence of food allergies among schoolchildren. Objectives The first goal of the survey was to estimate the prevalence of food allergies. The second goal was to determine the main characteristics of the allergies. Methods The questionnaires (3500) were distributed in 150 classes in eight schools. The return rate was 77.6% (2716). Results Of the 192 (7.0%) questionnaires with a ‘Yes’ response (report of a food allergy), 182 were retained as reporting true food allergies (6.7%). The cumulative and point prevalences were 6.7% [95% confidence interval (CI) 5.8–7.6] and 4.7% [95% CI 3.9–5.5], respectively. The point prevalences were 4.0% for the children aged 2–5 years, 6.8% for the children aged 6–10 years, and 3.4% for the children aged 11–14 years. The main foods reported as causing adverse reactions were cow milk (n=29, 11.9%), eggs (n=23, 9.4%), kiwis (n=22, 9.0%), peanuts (n=20, 8.2%), fish (n=19, 7.8%), tree nuts (n=19, 7.8%), and shrimp (n=13, 5.3%). The average age at which the allergies were detected was 3.4±2.8 years (with a range of 0.1–12 years). The clinical signs of the food allergies were cutaneous (n=153, 62.7%), digestive (n=74, 30.3%), respiratory (n=17, 6.9%), and anaphylactic shock (n=12, 4.9%). Conclusion While well aware of the biases inherent in this type of study, we estimated the cumulative and point prevalences of food allergies in a population of schoolage children in Toulouse at 6.7% and 4.7%, respectively. Cow milk, eggs, and peanuts were the main foods reported as causing allergies. Exotic fruits, shellfish, and tree nuts appeared to be relatively new allergens.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 8 - p. 698-700

Reminder of the aim of clinical practice recommendations (CPR). The ever more rapid development of new techniques and the diffusion of large amounts of information in the medical literature make it difficult for clinicians to assimilate and synthesize everything, giving rise to major variations in practices that are sometimes inappropriate or even unnecessary. This situation has led several countries to establish recommendations for treatment, diagnosis, prevention methods and disease care. These recommendations aim to help clinicians in decision-making by offering a synthesis with a certain level of scientific proof or professional consensus.

Extruded Low Voltage (LV) cables systems are ageing and an assessment of their condition is now necessary to build up a strategy regarding the management of this asset. This paper describes on the one hand the symptoms observed on faulty LV cables and branching joints by means of visual examination, material and electrical measurements in Laboratory. On the other hand, the paper describes the different investigations done in order to control and improve the quality of new LV extruded cable systems. (4 pages)

The increase of the load of some Medium Voltage (MV) cables, due to, amongst other things, the development of decentralized production, brings up “new” issues. A practical case of failure in Belgian MV cable networks, highlighted the importance of the thermal characteristics of the soil around highly loaded cables. An analysis of the thermal physical parameters of three types of soil (backfill, sandy and “local soil” type) used around the Belgian cable networks was performed. In order to assure good heat evacuation during the life time of the cable, the characteristics of the soil around loaded MV cables, especially if a “local soil” is used, have to be defined by a set of parameters and not only by the thermal resistivity. (4 pages)

Resume L'efficacite du surfactant artificiel chez les nouveau-nes atteints de detresse respiratoire aigue est maintenant bien demontree, mais les modalites optimales de son administration sont encore discutees. Population et methodes. —Les parametres gazometriques et le rapport alveoloarteriel (a/A) en oxygene ont ete etudies au cours des 24 premieres heures suivant l'administration d'Exosurf ® chez 400 nouveau-nes âges de 25 et 42 semaines d'amenorrhee. Resultats. —Apres la premiere dose, une reponse positive a l'administration de surfactant (obtention d'un rapport a/A superieur a 0,22 ou augmentation d'au moins 25 du rapport a/A) a ete obtenue dans 64 % des cas dans les 6 premieres heures et dans 11 % des cas entre 6 et 12 heures. Une reponse positive a la deuxieme dose a ete observee dans 75 % des cas. A la 24 e heure, 63 % des enfants ont atteint un rapport a/A superieur a 0,22. Conclusion. —L'existence de 18 % d'enfants ne repondant qu'a la deuxieme dose justifie l'usage de celle-ci meme en l'absence de reponse a la dose initiale. La qualite de la reponse au traitement est correlee a la severite de l'atteinte pulmonaire mais reste independante de l'âge gestationnel.

The present study was designed to assess the effect of adrenaline on the plasma concentrations of fentanyl in mothers and umbilical vessels after epidural administration for caesarean section. Thirty patients undergoing elective caesarean section were allocated randomly into two groups. Group 1 (n = 16) received 100 microg fentanyl, 10 ml of 0.5% bupivacaine and 10 ml 2% lidocaine, while group II (n = 14) received 100 microg fentanyl, 10 ml of 0.5% bupivacaine with adrenaline 1:200 000, and 10 ml of 2% lidocaine with adrenaline 1:80 000. Blood samples were obtained from the maternal antecubital vein (MV) at various times up to 6 hours after epidural injection, and from umbilical vein (UV) and arteries (UA) at birth for determination of plasma fentanyl by radioimmunoassay. Fentanyl Cmax and Tmax in MV did not differ significantly between the two groups. In umbilical vessels, plasma fentanyl concentrations were comparable in the two groups: (0.12 +/- 0.08 ng ml(-1) and 0.13 +/- 0.08 ng ml(-1) in UV and 0.08 +/- 0.07 ng ml(-1) and 0.06 +/- 0.05 ng ml(1) in UA of groups I and II respectively). The maximum plasma concentration in UV was 0.24 ng ml(-1) in group I and 0.25 ng ml(-1) in group II. There was no significant correlation between umbilical vessel (vein or artery):MV ratio and dose to delivery interval and no difference between the two groups in Apgar score or umbilical cord pH.

OBJECTIVE: The aim was to determine the sensitivity and specificity of a short femur for detection of trisomy 21 in the second trimester. STUDY DESIGN: Thirty-six investigators in 12 centers measured biparietal diameter and femur and foot lengths in 3582 14- to 24-week-old fetuses in mothers undergoing amniocentesis for age, history of genetic disorder, or laboratory signs. RESULTS: Among the various ratios for evaluating femur shortening the femur/foot ratio appeared to be the most discriminatory. At an upper cutoff level of 0.88 a sensitivity of 35% was obstained for 4.6% false positives in normal infants. However, to only obtain 2.3% false positives, the cutoff limit had to be set at 0.85, giving a sensitivity of no more than 15%. CONCLUSION: Determination of the femur/foot ratio improves ultrasonographic detection of trisomy 21 in the second trimester, although for systemic use it would lead to an unacceptable number of unnecessary amniocenteses.

Objective To investigate whether an internet based, nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinically manifest vascular disease. Design Prospective randomised controlled trial. Setting Multicentre trial in secondary and tertiary healthcare setting. Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with at least two treatable risk factors not at goal. Intervention Personalised website with an overview and actual status of patients’ risk factors and mail communication via the website with a nurse practitioner for 12 months; the intervention combined self management support, monitoring of disease control, and drug treatment. Main outcome measures The primary endpoint was the relative change in Framingham heart risk score after 1 year. Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor. Results Participants’ mean age was 59.9 (SD 8.4) years, and most patients (n=246; 75%) were male. After 1 year, the relative change in Framingham heart risk score of the intervention group compared with the usual care group was −14% (95% confidence interval −25% to −2%). At baseline, the Framingham heart risk score was higher in the intervention group than in the usual care group (16.1 (SD 10.6) v 14.0 (10.5)), so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score. This produced a relative change of −12% (−22% to −3%) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and −8% (−18% to 2%) adjusted for the baseline score. Of the individual risk factors, a difference between groups was observed in low density lipoprotein cholesterol (−0.3, −0.5 to −0.1, mmol/L) and smoking (−7.7%, −14.9% to −0.4%). Some other risk factors tended to improve (body mass index, triglycerides, systolic blood pressure, renal function) or tended to worsen (glucose concentration, albuminuria). Conclusion An internet based, nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease. Trial registration Clinical trials NCT00785031.

Reminder of the aim of clinical practice recommendations (CPR). The ever more rapid development of new techniques and the diffusion of large amounts of information in the medical literature make it difficult for clinicians to assimilate and synthesize everything, giving rise to major variations in practices that are sometimes inappropriate or even unnecessary. This situation has led several countries to establish recommendations for treatment, diagnosis, prevention methods and disease care. These recommendations aim to help clinicians in decision-making by offering a synthesis with a certain level of scientific proof or professional consensus.

AIM To explore factors associated with students' attitudes towards their peers with disabilities. METHOD All 7th grade students (aged 12-13y) from 12 schools in the Toulouse area were invited to participate (n=1509). Attitudes were measured using the Chedoke-McMaster Attitudes Towards Children with Handicaps (CATCH) questionnaire (affective, behavioural, cognitive, and total scores). Personal characteristics, including KIDSCREEN quality of life scores, were recorded. Data regarding information about disabilities received from parents and the media and acquaintance with people with disabilities constituted the 'disability knowledge' factors. The characteristics of the schools were obtained from the local education authority. Multivariate multilevel linear regression analyses were conducted to explore the associations between CATCH scores and these three groups of factors. RESULTS Responses from 1135 students (612 females, 523 males; mean age 12y 8mo SD 7mo; age range 10y 8mo-15y) were studied (75.2% of the students approached). Factors independently associated with more positive attitudes were being a female, having a good quality of life, being friends with a child with disabilities, or having received information about disabilities from parents and the media. Presence in the school of a special class for children with cognitive disabilities was independently associated with more negative attitudes. INTERPRETATION This cross-sectional study identified different personal and environmental factors upon which interventions aimed at improving students' attitudes towards their peers with disabilities could be based.

The influence of pH variations on transplacental transfer of antipyrine was studied using a human placental cotyledon perfused ex vivo. The antipyrine transfer rate is positively correlated with the pH in the fetal circulation and negatively correlated with the pH in the maternal circulation. Thus, the transfer rate is negatively correlated with the difference between pH values in maternal and fetal circulations. The antipyrine transfer rate is also positively correlated with the flows in maternal and fetal circulations. The above parameters allowed to explain 50% of the variance on the transfer rates obtained in various experimental conditions. In a final series of experiments where these parameters for each placenta were fixed at identical values, a good reproducibility in the results was obtained, the variation coefficient being 17%. Thus, establishing the effect of variations in pH allowed a good standardization of the perfused cotyledon model. This effect cannot be explained by modifications in the ionized fraction of the antipyrine molecular and is probably due to physiological mechanisms.

Inspite of unquestionable progress, the protection of girls at first sexual intercourse is still not perfect. The main risks are well known (sexually transmitted infections [STIs], unwanted pregnancies, psychological consequences) and seem to be higher in the case of early sexual initiation. The aim of this epidemiological study is to analyse factors associated with early heterosexual intercourse (age 15 or before) among girls, considered as risk factors for pregnancies and STIs.Our data come from the 2002 international survey Health Behaviour in School-aged Children (HBSC)/WHO. The questionnaire is completed anonymously in class and measures health, health behaviours and their contexts among 11-, 13- and 15-year-old students. Only the 15 year-olds are asked about their sexual behaviour. In France, 1264 15-year-old (plus or minus six months) girls have answered the survey.Two hundred and twenty-four girls (17,7 %) state they have already had sexual intercourse. Among these, 88,4 % say that condoms and/or pills were used at last sexual intercourse. Multivariate analysis (n=1159) show that seven variables are significantly and independently linked to a higher frequency of early sexual intercourse: single-parent or reconstructed family, repeated drunkenness, daily smoking, cannabis experimentation, frequent evenings out, negative life appreciation and early menarche.Identifying factors associated with early sexual initiation should help professionals to better take care of those high risk adolescent girls.

The KidlQol is a self-evaluation computer-based instrument to assess the quality of life of children aged 6 to 12 years old. This self-evaluation comprises three areas of their subjective quality of life: physical, psychological and social. A computer-assisted tool, composed of 62 items, was developed and set up based upon the results from the evaluation of the initial prototype tool which underwent a series validation steps, tested among children with and without psychological problems. This evaluation lead to the production of a final tool called KidlQuol, which is composed of 44 items. This tool, which utilises computer images to represent real-life situations, is adapted for and accessible to children with a French cultural background aged between 6 and 12 years old. As a generic tool, it could be used among a population of children with various types of handicaps, chronic diseases or psycho-social difficulties.

The objective of this work was to assess the quality of life of children aged 6 to 12 years old. The authors present the different conceptual and operational steps which lead to the construction of a prototype tool. It was a generic tool composed of 63 items which covered the classically described areas of life. Its originality was due to the method of construction used which included children's involvement, to the pictorial representation of real-life situations for children, and to its adaptation for gender. The evaluation of this tool showed a good level of acceptability but statistical analysis revealed some metrological inadequacies leading to the reconsideration of the initial concepts and their methods of exploration. Therefore a new tool was constructed whose validation is presented in a second article in the next issue.

Weight loss is frequently observed in patients with Alzheimer's disease (AD), as observed in clinical practice and reported in the literature. However, information on the evolution of nutritional status and its impact on the prognosis of AD is still scarce.Our aim was to determine the impact of nutritional status on the evolution of AD and on the response to treatment with acetylcholinesterase inhibitors (AChEI) by prospective one-year follow-up of AD patients living at home.We studied a cohort of 523 patients with Alzheimer's disease referred from 1994 to 2002 to an Alzheimer centre. After diagnosis, they were followed for one year in a prospective observational study in clinical practice. At entry and every 6 months, patients underwent standardised neurocognitive and geriatric evaluation (MMSE, ADAS-cog, IADL, MNA, caregiver burden). These evaluations were accompanied by complete clinical examination, standard paraclinical investigations and recording of treatment received.Of our patients, 25.8% presented at inclusion a risk of undernutrition with an MNA score of 23.5 or less. During follow-up, the number of patients with rapid loss on the MMSE (3 points or more in one year) was higher in subjects who presented a risk of undernutrition at inclusion (53.6%) than in well-nourished subjects (43.2%) (P = 0.07). Similarly, increased dependence at one year was more frequent in subjects at risk of undernutrition at inclusion (57.7% versus 44.4%, P = 0.0219). The beneficial effect of AChEI treatment on cognitive function was not influenced by initial nutritional status; on the contrary, among the subjects at risk of undernutrition at inclusion, the risk of rapid loss on the MMSE in one year was decreased in subjects treated during follow-up compared with untreated subjects (43.9% versus 73.1% ; OR = 0.29; 95% CI = 0.10-0.83; P = 0.0219). This relationship was not found in subjects whose initial MNA score was greater than 23.5.Our work indicates that AD patients living at home with a caregiver are frequently at risk of undernutrition. Undernourished patients seem to present more rapid aggravation of the disease, but paradoxically, these patients appear to be those who best respond to AChEI treatment.

To assess the frequency of deprivation in pregnant women and estimate the associated medical risks.and methods. A retrospective study of the hospital's computerised data (6149 women) and two prospective studies with health staff (n=534) and social workers (n=85) in two maternity hospitals.In the retrospective study, 17.5% of mothers were deprived. Deprivation was associated both with more difficulties during pregnancy and the perinatal period and with longer hospital stays. The prospective studies confirmed the prevalence of deprivation and gave a more detailed idea of the associated social and demographic characteristics. Deprivation was related with a combination of risk factors with a particularly important influence of economic risk. A quarter of deprived mothers had unwanted pregnancies and according to the social workers approximately 10% of them were not in a position to take care of their baby.This study emphasizes the importance of deprivation as a perinatal medical risk factor. Screening should take place in early pregnancy in order to find the best way to help such families.

Objective To investigate the outcome of fetuses affected by congenital heart defects (CHD), either detected or undetected at ultrasound screening, according to their complexity and severity. Design The study group comprised 3633 malformed fetuses entered into the Eurofetus database of which 798 had CHD. We compared the short-term outcome in cases where a CHD was detected by ultrasound screening with that in cases where a CHD was not detected. Isolated and associated CHD (ICHD and ACHD) and the degree of severity of defects were considered separately. Outcome data included termination of pregnancy (TOP), intrauterine fetal death, neonatal death (< 6 days after birth), gestational age at diagnosis and at delivery, mode of delivery and birth weight. Results Of the 798 fetuses with CHD, 595 had ICHD and 203 had ACHD. The diagnosis of an anomaly was made significantly earlier in ACHD cases. TOP was chosen in 28% of cases with a prenatal diagnosis of CHD, 20% for ICHD and 37% for ACHD (P < 0.001). The survival rate of antenatally diagnosed fetuses was lower in those with ACHD than in those with ICHD (P < 0.001) and lower for fetuses with antenatal diagnosis than with postnatal diagnosis (P < 0.001); this was due to significant differences in the complexity and severity of the defect. Premature delivery (< 32 weeks) was more frequent in fetuses in which an antenatal diagnosis of CHD had been made. Severe CHD were diagnosed earlier and were associated with a higher rate of TOP and spontaneous loss. Conclusions The severity of CHD has a positive influence on the sensitivity of screening but a negative influence on the outcome. CHD that are not diagnosed antenatally include a high proportion of benign malformations. This explains the apparent paradox of a poorer outcome in fetuses in which a CHD was detected prenatally compared to those fetuses in which the defect was undetected prenatally. However, prenatal diagnosis provides parents with the option of TOP or of preventive care in specialized centers. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

To assess the influence of heart defect frequency and severity on screening sensitivity of the entire spectrum of congenital anomalies (CA) and on detection rate of congenital heart defect (CHD) when performing routine ultrasound screening in unselected pregnant women.Secondary analysis was performed on data from Eurofetus, a large international collaborative study of ultrasound screening for CA in unselected populations. The present study addressed the relations (i) between the frequency of CHD in the screened population and the global sensitivity of ultrasound in detecting CA; (ii) between frequency of ventricular septum defect (VSD) and detection rate of CA and CHD; and (iii) between seriousness of CHD and CHD sensitivity.A negative correlation (p0.001) between CHD frequency and CA sensitivity was observed in this study. Likewise, a negative correlation was also found between frequency of VSD and sensitivity for CA or CHD detection (p0.001). In addition, a positive significant relationship (p0.001) was observed between sensitivity and severity of CHD.A low CHD frequency introduces bias in CA and CHD sensitivity evaluation. Incomplete assessment of fetal and neonatal malformations brings on systematic error, leading to the pre-eminence of severe defects in the studied population sample and artificially improving sensitivity figures. On the other hand, from a clinician's viewpoint, the higher sensitivity for severe defect is welcomed, since their detection is most crucial for appropriate management.

Amongst factors associated with the institutional placement of elderly people with dementia, there has been little study of those related to malnutrition. We followed a cohort of 318 individuals with Alzheimer's disease (AD). Patients, who were all living at home at the start of the study were recruited from the outpatient service of a hospital unit specialising in AD. After one year, 20% of the patients had moved into institutional care. Multivariate analysis showed that a Mini nutritional Assessment score (MNA) of less than 25.5 (median score of the sample) and overeating behavioural problems (p=0.006) were risk factors for institutional placement. Nutritional problems are reversible and patients with a low MNA score could benefit from a thorough geriatric assessment, in order to slow or prevent institutional placement.

We sought a relationship between disorders of the narcissistic transition during pregnancy and post-partum depression. We designed a self-report questionnaire VASANT (Visual Analogic Scale for Assessment of Narcissistic Transition) in an attempt to identify women at risk from post-partum depression. A preliminary validation was carried out on 52 pregnant women. Seventeen women (33%) were identified using a semi-directive interview as suffering from a disorder in the narcissistic transition. These women had a significantly higher VASANT score (67.7 +/- 14.2 versus 20.2 +/- 8.4) than the others and had a higher incidence of post-partum depression. The value of the VASANT scale for prediction of post-partum depression is discussed.

Objectives: To study body composition in elderly osteoporotic women to determine the relationship of body weight, body fat mass and lean mass to bone mineral density (BMD), and to investigate the association between one-leg balance, osteoporosis and sarcopenia. Design and Setting: A cross-sectional study of a community-based population in Toulouse, France. Methods: For each participant, whole body composition and BMD were estimated using a dual-energy x-ray absorptiometry scanner. We investigated balance using a one-leg balance test. Participants: 129 healthy women aged 75–89 years, volunteers, ambulatory and living at home. Results: Total fat mass and appendicular skeletal muscle mass (ASM) were significantly lower in osteoporotic women than in the age- and sex-matched non-osteoporotic controls [18.7 ± 4.6 vs. 22.2 ± 6.6 for total fat mass (p < 0.01); 13.1 ± 1.6 vs. 13.8 ± 2.2 for ASM (p < 0.05)]. We did not find a positive association between osteoporosis and sarcopenia (OR = 0.75, CI 0.3–1.84), osteoporosis and one-leg balance (OR = 1.27, CI 0.51–3.17), or sarcopenia and one-leg balance (OR = 1.31, CI 0.52–3.36). There were significant positive correlations between BMD in all areas and body measurements (weight, fat mass, lean tissue mass), but fat mass accounted for more of the variance in total body and femoral BMD than lean tissue mass. Total fat mass alone, in a multivariate model, was correlated with whole body BMD, whereas femoral BMD was associated with both fat mass and lean tissue mass. Conclusion: Higher values of fat mass and lean tissue mass may have a protective effect on femoral bone density. Sarcopenia and osteoporosis are not necessarily linked with balance.

Based on data from the EPIDOS prospective study, we have shown that femoral bone mineral density (BMD), calcaneal ultrasound measurements and fall-related factors are significant predictors of the risk of hip fracture. The goal of the present investigation, in the same cohort of elderly women, was (1) to assess and compare the value of femoral BMD, calcaneal broadband ultrasound attenuation (BUA), gait speed and age for identifying elderly women at high risk of hip fracture and (2) to determine whether combining two or more of these measurements would improve predictive ability over single measures. A total of 5895 elderly women had baseline measurements of femoral neck BMD by dual-energy X-ray absorptiometry, calcaneal BUA and gait speed. During an average of 33 months of follow-up, 170 women suffered a hip fracture. We compared the sensitivity and specificity of single and combined measures for three specific cutoff levels to define high risk, i.e., the median, the top quartile and the top decile of risk. We found that femoral BMD, calcaneal BUA, gait speed and age have approximatively the same discriminant value to identify women at high risk of hip fracture even though certain measures and combinations of measures have a significantly higher sensitivity for certain cutoff levels. The sensitivity of the available screening tools is low, even when they are combined: to obtain a sensitivity of about 80%, approximately 50% of the population must be considered to be at high risk.

Regulations concerning services for handicapped children in France have defined the notion of multi-handicap. There are, however, divergences in the procedures for applying this definition, and differences in the prevalence in different areas. This study is aimed at clarifying these two points.A survey in three French departments provided data about disabled children born between 1975 and 1985 who received services from the departmental committee for special education or from day hospitals. The data was systematically collected by a physician using medical files.The results showed that the group of multi-handicapped children was heterogeneous. The most restrictive definition (motor disability with profound mental retardation, bed-ridden or restricted to a chair) resulted in a prevalence of 0.73%. A broader definition based on the concept of zero autonomy, but excluding mild or moderate mental retardation, resulted in a prevalence of 1.28%.The importance of specifying the objectives of a definition selected for operational reasons is stressed in order to improve the estimation of specific needs.

Chromosomal abnormalities were recorded from all the fetuses of women who benefited from sonographic examinations in the Eurofetus centers, excluding those for whom karyotyping was motivated by age or personal history. Among the 378 chromosomal abnormalities recorded, 210 were detected before birth (sensitivity = 55.6%). Down syndrome (trisomy 21) represented 197 cases, or which 68 were detected before birth (sensitivity = 34.5%). Eighty-two of the cases of Down syndrome had associated structural abnormalities; the sensitivity in these cases increased to 57%. Among the 115 cases of Down syndrome without structural abnormalities, 21 (18.3%) had associated abnormal ultrasound findings that led to prenatal detection. Sensitivity of prenatal detection was 58.1% for trisomy 13 and 79% for trisomy 18. For the abnormalities detected before birth, spontaneous fetal death occurred in 27% of cases, and an early termination of pregnancy was decided in 53% of cases.

In this prospective study, we recorded details on 3,685 fetuses with congenital structural abnormalities from an unselected population of women who underwent routine ultrasound examinations during their pregnancies. Overall, 2,262 fetuses were diagnosed as being abnormal before birth (sensitivity = 61.4%). The total number of abnormalities was 4,615, of which 1,733 (37.5%) were major abnormalities. The overall number of detected abnormalities was 2,593 (sensitivity = 56.2%). If only major abnormalities were considered, the sensitivity rose to 73.7%, compared to only 45.7% for the minor abnormalities. Within each severity group, the accuracy of detection varied across systems. For the major abnormalities, it was higher for the central nervous system (88.3%) and urinary tract (84.8%), but lower for heart and great vessels (38.8%). Detection of minor abnormalities was also effective for the urinary tract (89.1%), but not for the heart and great vessels (20.8%) and the musculoskeletal system (18%).

Early menopause due to an exhaustion of the ovarian follicles before the age of 40 years occurs in approximately 1% of women in this age range. Clinical signs of estrogen deficiency with amenorrhea and sterility are usually confirmed by hypergonadotrope hypogonadism at laboratory tests. The syndrome is to be differentiated from gonadotrophine resistant ovaries and rare gonadotrope adenomas. Ovary biopsy shows more or less complete destruction of the follicles. There are many causes of early menopause including abnormal number or structure of chromosome X in 15-20% of the cases. Certain metabolic disorders and viral infections can also be incriminated. Finally surgery, radiotherapy or chemotherapy can be the cause of iatrogenic menopause. To determine prognosis, the woman's follicular capacity must be estimated. Estrogen therapy is currently the best choice to preserve chances for ovulation and pregnancy. When there is no remaining follicular capacity, ovum donation may be a solution. Finally, all patients should be given hormone substitution therapy due to the long-term risk of estrogen-progesterone deficiency.

We carried out orthotopic autografts of ovarian tissue on 15 Wistar rats. One ovary has been removed and cut in 2 or 3 slices. The other ovary has been removed, and the controlateral slices grafted in the empty ovarian bursa by mean of a microscope, without vascular anastomosis. The endocrine function of the graft was assessed by checking the vaginal smears. The animals were mated. Two of them became pregnant with normal offsprings, two others has vaginal bleeding which could be miscarriages. This experimentation suggests that the orthotopic autograft of ovarian slices is possible in rats. The endocrine function of the ovary is restored with a very good rate. Fertility is restored for a small proportion of animals.

There is now good evidence that the clinical course of infants with respiratory distress syndrome can be improved by treatment with exogenous surfactant. However, optimal methods of giving such a treatment are still debated.The arterial blood gases and the arterial/alveolar oxygen tension ratio (a/A) were recorded during the 24 hours following artificial surfactant (Exosurf) treatment in 400 newborns aged 25 to 42 gestational weeks. A positive response was defined by an a/A ratio0.22 or an increase in a/A ratio up to 25%.After administration of the first dose, a positive response was obtained in 63% of cases during the first 6 hours and 11% during the 6 following hours. The response after the second dose was favourable in 75% of cases. At 24 hours after treatment, 36% of the infants had obtained an a/A ratio0.22.Because of the 18% of infants who responded positively only after the second dose, administration of this dose seems justifiable even in case of non-response to the first dose. The quality of the response is related to the severity of the pulmonary illness but is independent of the gestational age.

The identification of intrauterine growth retarded infants remains a problem. It is useful to distinguish between small for date which uses the reference of a statistical birthweight limit and intrauterine growth retardation. A study comprising nearly 100,000 births from many French regions allowed a definition of the limits of birthweights taking into account gestational age, sex, birth rank, maternal height and pregravid maternal weight. This new approach distinguished two groups of newborns, the "constitutionaly small" and those who are newly called "growth retarded". The validity of this new classification is discussed.

The collection of nearly 100,000 births from 22 maternity hospitals in various French regions permitted to establish foetal growth curves for weight, height and head circumference. The 50th percentiles of weight at term obtained in this sample are not different from those given by Leroy and Lefort in the Paris region in 1971. However below 38 weeks of gestation, we found that 50th percentiles are 100 or 150 g less than those given by Leroy and Lefort. The discussion from international papers show large variations of the 10th percentile for weight in according to gestational age and sex, these variations are often related to the choice of different target populations.

To determine the sensitivity and specificity of soft-tissue nuchal-fold measurement in the second-trimester fetus for the detection of trisomy 21.Thirty-six investigators in 12 centers measured nuchal skinfold thickness in 3308 fetuses of 14-24 weeks' gestation. All mothers were referred for amniocentesis because of age, history of genetic disorder, or laboratory findings. Those referred with an ultrasound indication for amniocentesis, including nuchal-fold thickening, were excluded.Overall, nuchal skinfold was 6 mm or more in 8.5% of chromosomally normal fetuses and in 38% of those with trisomy 21. A false-positive rate below 5% was obtained by 81% of the investigators. Raising the cutoff of normality to 7 mm after 18 weeks' gestation improved specificity.Although the diagnostic value of this sign in skilled hands could allow its use as an indication for genetic amniocentesis at the second trimester, the method does not appear suitable for population screening because of the high variability in the results among the investigators.

The origins of the Cesarian section date back to the Classical era, and possible even earlier. Ancient India, the Hebrews, the Grecks and the Romans were all familiar with post-mortem Cesarian section. The operation marked time during the Middle Ages. The name "Cesarian section" was first used to designate this operation during the Renaissance period, when it was first carried out in live women. However, until the middle of XIX th century, a Cesarian remained a last chance option which was cautioned against by most obstetricians. It was only after the advent of the "surgical golden tripod" that the Cesarian was gradually rehabilitated through the work of Poro, Kherer and Sanger and the German School. In the XIXth century, segmental incision became the norm and fetal indications for a Cesarian emerged.

Data concerning neonates with acute respiratory distress syndrome (RDS) are still scarce. The characteristics and follow-up of a French cohort which has participated in an international trial concerning the efficacy of artificial surfactant have been studied.One thousand one hundred and fifty-seven neonates admitted from October 1990 to December 1991 in 27 French intensive care units because of RDS due to hyaline membrane disease were included in the study, whatever their birthweight and gestational age (GA).Three hundred and sixteen neonates (27.3%) were born from twin or multiple pregnancies. Fourty-five (5.5%) of the mothers had been given corticosteroids for the week preceding delivery. 55.5% were delivered by cesarean section. Mean GA was 31.0 +/- 2.9 weeks and mean birth-weight was 1,603 +/- 625 g. Two hundred and sixty-six neonates (23%) were small for GA. Two hundred and twenty-three died after a mean survival of 4.2 days (63% before the end of the first week and 80% before the end of the third week). Fifty percent of these deaths were due to respiratory distress, 28% to severe brain disorders and 9% to infections. The bronchopulmonary dysplasia rate was 21.7%. Early ultrasound scan of the brain showed major injuries in 19.5% of cases; the second scan performed in 822 infants was normal in 84.3%.Taking into account GA, mortality and morbidity rates were similar to those of the other non-French participating centres.

We studied the different motivations mothers had for choosing a particular mode of nursing at the University Hospital in Limoges. An anonymous questionnaire was distributed to all mothers who hat delivered between January 1 and April 30, 1992. It was apparent that the medical team did little to promote breast-feeding or to counteract negative attitudes. The results of this study, together with a review of the literature were used to determine conditions for encouraging breast feeding.